Comparison of circulating proinflammatory cytokines and soluble apoptosis mediators in patients with chronic heart failure with versus without symptoms of depression

The Heart Is at Risk: Understanding Stroke-Heart-Brain Interactions with Focus on Neurogenic Stress Cardiomyopathy-A Review

In recent years, it has been convincingly demonstrated that acute brain injury may cause severe cardiac complications-such as neurogenic stress cardiomyopathy (NSC), a specific form of takotsubo cardiomyopathy. The pathophysiology of these brain-heart interactions is complex and involves sympathetic hyperactivity, activation of the hypothalamic-pituitary-adrenal axis, as well as immune and inflammatory pathways. There have been great strides in our understanding of the axis from the brain to the heart in patients with isolated acute brain injury and more specifically in patients with stroke. On the other hand, in patients with NSC, research has mainly focused on hemodynamic dysfunction due to arrhythmias, regional wall motion abnormality, or left ventricular hypokinesia that leads to impaired cerebral perfusion pressure. Comparatively little is known about the underlying secondary and delayed cerebral complications. The aim of the present review is to describe the stroke-heart-brain axis and highlight the main pathophysiological mechanisms leading to secondary and delayed cerebral injury in patients with concurrent hemorrhagic or ischemic stroke and NSC as well as to identify further areas of research that could potentially improve outcomes in this specific patient population.

Cognitive Impairment in Acute Heart Failure: Narrative Review

Cognitive impairment (CI) represents a common but often veiled comorbidity in patients with acute heart failure (AHF) that deserves more clinical attention. In the AHF setting, it manifests as varying degrees of deficits in one or more cognitive domains across a wide spectrum ranging from mild CI to severe global neurocognitive disorder. On the basis of the significant negative implications of CI on quality of life and its overwhelming association with poor outcomes, there is a compelling need for establishment of detailed consensus guidelines on cognitive screening methods to be systematically implemented in the population of patients with heart failure (HF). Since limited attention has been drawn exclusively on the field of CI in AHF thus far, the present narrative review aims to shed further light on the topic. The underlying pathophysiological mechanisms of CI in AHF remain poorly understood and seem to be multifactorial. Different pathophysiological pathways may come into play, depending on the clinical phenotype of AHF. There is some evidence that cognitive decline closely follows the perturbations incurred across the long-term disease trajectory of HF, both along the time course of stable chronic HF as well as during episodes of HF exacerbation. CI in AHF remains a rather under recognized scientific field that poses many challenges, since there are still many unresolved issues regarding cognitive changes in patients hospitalized with AHF that need to be thoroughly addressed.

Asthma Across the Ages: Adults

Asthma is a common disease affecting approximately 300 million people worldwide, across all age ranges. Despite advances in asthma outcomes of the last few decades, there remains room for improvement in asthma management and for patient outcomes, particularly in older patients. The heterogeneity of asthma is now well recognized, and is known to complicate response to treatment and patient behavior and impact health outcomes. Asthma and its heterogeneity change according to age. Asthma affects people differently across the life span. In adults, prevalence is highest among those in middle age; however, mortality is greater in the older age group. In this clinical commentary, we describe how age impacts asthma prevalence and incidence, outcomes, disease expression, and approach to management in adulthood and in older patients.

The Impact of Disease Comorbidities in Alzheimer's Disease

A wide range of comorbid diseases is associated with Alzheimer's disease (AD), the most common neurodegenerative disease worldwide. Evidence from clinical and molecular studies suggest that chronic diseases, including diabetes, cardiovascular disease, depression, and inflammatory bowel disease, may be associated with an increased risk of AD in different populations. Disruption in several shared biological pathways has been proposed as the underlying mechanism for the association between AD and these comorbidities. Notably, inflammation is a common dysregulated pathway shared by most of the comorbidities associated with AD. Some drugs commonly prescribed to patients with diabetes and cardiovascular disease have shown promising results in AD patients. Systems-based biology studies have identified common genetic factors and dysregulated pathways that may explain the relationship of comorbid disorders in AD. Nonetheless, the precise mechanisms for the occurrence of disease comorbidities in AD are not entirely understood. Here, we discuss the impact of the most common comorbidities in the clinical management of AD patients.

The Interactions Between Alzheimer's Disease and Major Depression: Role of Ca2+ Channel Blockers and Ca2+/cAMP Signalling

BACKGROUND

The interactions between Alzheimer's Disease (AD) and major depression can be translated into clinical data showing that depressive patients have had an enhanced risk for developing AD (later in life). The cellular mechanisms involved in these interactions remain under intensive debate in the literature. In addition, the role of a Ca²⁺ homeostasis dysregulation in the pathogenesis of neurodegenerative diseases, like AD, and major depression has been under intensive discussion.

OBJECTIVE

Thus, revealing the interplay between AD and major depression may provide novel insights into the pathogenesis of these diseases.

METHODS

Publications involving Ca²⁺ signalling pathways, AD, and major depression (alone or combined) were collected by searching multiple databases to find the maximum number of relevant citations (using a search strategy with high sensitivity for studies of etiology).

RESULTS

Ca²⁺ Channel Blockers (CCBs), classically prescribed for hypertensive patients, have been demonstrating neuroprotective effects, such as decreasing the incidence of AD in hypertensive patients, including alleviating major depression symptoms. A mechanism under debate is focused on the restoration of the Ca²⁺ homeostasis. Indeed, previous studies of our own have correlated Ca²⁺ and cAMP signalling pathways (Ca²⁺/cAMP signalling) in controlling both the neurotransmitter release and neuronal death. These studies also observed that CCBs can affect Ca²⁺/cAMP signalling.

CONCLUSION

This review discussed the plausible role of Ca²⁺/cAMP signalling in the neuroprotective effects of CCBs, including the participation of Ca²⁺/cAMP signalling in the interactions between major depression and AD. Considering both AD and major depression have become highly prevalent medical problems in the world, the comprehension of the interactions between these diseases could improve drug development.

Particulate matter exposure disturbs inflammatory cytokine homeostasis associated with changes in trace metal levels in mouse organs

Few studies have focused on the impact of particulate matter (PM) exposure with respect to the relationship between PM-induced inflammation and the levels of trace metals in tissues and organs. In this study, C57BL/6 male mice were exposed to ambient air alongside control mice breathing air filtered through a high-efficiency particulate air (HEPA) filter. In both groups, mRNA levels of pro- and anti-inflammatory cytokines were measured after 4, 8 and 12 weeks together with the trace metal contents of the lungs, heart, liver, hippocampus and blood. PM exposure resulted in a general upward trend in the levels of pro-inflammatory cytokines in lung, heart, liver and hippocampus. By contrast, IL-10 mRNA expression varied depending on the organ, with a continuous upward trend in heart and liver and an up-regulation at 8 weeks followed by a down-regulation at 12 weeks in lung and hippocampus. The disturbed homeostasis of inflammatory cytokines was accompanied by changes in trace metal levels in the mice. These alterations may have constituted a compensatory effect conferring protection from inflammatory damage. However, prolonged PM exposure finally resulted in the deficiency of several essential trace metals in the lungs and hippocampus, which may have contributed to the observed histological changes typical of an inflammatory response.

Pharmacological Treatment of Depression in Alzheimer's Disease: A Challenging Task

Besides the memory impairment, Alzheimer’s disease (AD) is often complicated by neuropsychiatric symptoms also known as behavioral and psychological symptoms of dementia, which occur in one-third of patients at an early stage of the disease. Although the relationship between depressive disorders and AD is debated, the question if depression is a prodromal symptom preceding cognitive deficits or an independent risk factor for AD is still unclear. Moreover, there is growing evidence reporting that conventional antidepressants are not effective in depression associated with AD and, therefore, there is an urgent need to understand the neurobiological mechanism underlying the resistance to the antidepressants. Another important question that remains to be addressed is whether the antidepressant treatment is able to modulate the levels of amyloid-β peptide (Aβ), which is a key pathological hallmark in AD. The present review summarizes the present knowledge on the link between depression and AD with a focus on the resistance of antidepressant therapies in AD patients. Finally, we have briefly outlined the preclinical and clinical evidences behind the possible mechanisms by which antidepressants modulate Aβ pathology. To our opinion, understanding the cellular processes that regulate Aβ levels may provide greater insight into the disease pathogenesis and might be helpful in designing novel selective and effective therapy against depression in AD.

Chronic Systemic Symptoms in Head and Neck Cancer Patients

The systemic effects and manifestations of disease and treatment have been of interest for millennium. Until recently, basic and clinical research is just now reaching a watershed. Systemic symptoms usually do not occur in isolation but rather in clusters; however, much of the cutting-edge research pertaining to the etiology, mechanism, manifestations, and moderators of systemic symptoms in humans has been directed at individual symptoms, thus creating silos of knowledge. Breaching these silos and bridging the knowledge from disparate arenas of investigation to build a comprehensive depiction of acute and chronic systemic symptoms has been a challenge. In addition, much of the recent work in systemic symptoms has been conducted in the setting of nonmalignant disease. The degree to which the findings from other chronic disease processes can be translated into the oncologic realm is unknown. This article will explore inflammation as a major contributing factor to systemic symptoms and sickness behavior, discuss the most common manifestations in cancer survivors, and, where available, discuss specific data pertaining to head and neck cancer survivors.

Particulate Matter Triggers Depressive-Like Response Associated With Modulation of Inflammatory Cytokine Homeostasis and Brain-Derived Neurotrophic Factor Signaling Pathway in Mice

Particulate matter (PM) exposure may contribute to depressive-like response in mice. However, few studies have evaluated the adaptive impacts of long-term PM exposure on depressive-like response associated with systemic inflammation and brain-derived neurotrophic factor (BDNF) signaling pathway. We studied the association among depressive-like behaviors, mRNA levels of pro and anti-inflammatory cytokines, and the expression of BDNF signaling pathway in mice by long-term PM exposure. C57BL/6 male mice were exposed to ambient air alongside control mice breathing air filtered through a high-efficiency air PM (HEPA) filter. Depressive-like behaviors were assessed together with proinflammatory, anti-inflammatory cytokine mRNA levels and the modulation of BDNF pathway in hippocampus and olfactory-bulb of mice exposed to PM for 4, 8, and 12 weeks. Exposure to HEPA-filtered air for 4 weeks may exert antidepressant like effects in mice. Proinflammatory cytokines were up-regulated while the expression of BDNF, its high-affinity receptor tropomyosin-related kinase B (TrkB), and the transcription factor (cyclic adenosine monophosphate)-response element-binding protein (CREB) were down-regulated in ambient air mice. However, after 8 weeks, there was no significant difference in the rate of depressive-like behaviors between the 2 groups. After 12 weeks, mice exposed to ambient air again had a higher rate of depressive-like behaviors, significant up-regulation of proinflammatory cytokines, down-regulation of interleukin-10, BDNF, TrkB, and CREB than HEPA mice. Ultrafine PM in brain tissues of mice exposed to ambient air was observed. Our results suggest continuous high-level PM exposure alters the depressive-like response in mice and induces a damage-repair-imbalance reaction.

The Physical Burden of Immunoperception

The previous chapter introduced the ImmunoEmotional Regulatory System (IMMERS). Also, there was a brief discussion about psychological states/psychiatric disorders that so far have been linked to the IMMERS. The present chapter considers another aspect of the IMMERS in which physiological states/physical diseases can be fit to the IMMERS.

Cognitive decline in heart failure

Cognitive impairment (CI) is common in older adults with heart failure (HF). The prevalence of CI is higher among patients with HF than in those without. The spectrum of CI in HF is similar to that observed in the general population and may range from delirium to isolated memory or non-memory-related deficits to dementia. Both HF with reduced ejection fraction and HF with preserved ejection fraction have been associated with defects in different domains of cognition. Numerous risk factors have been shown to contribute to CI in HF. Additionally, various pathophysiological mechanisms related to HF can contribute to cognitive decline. These conditions are not routinely screened for in clinical practice settings with HF populations, and guidelines on optimal assessment strategies are lacking. Validated tools and criteria should be used to differentiate acute cognitive decline (delirium) from chronic cognitive decline such as mild cognitive impairment and dementia. CI in HF has been associated with higher rates of disability and impairment in self-care activities that may in turn increase healthcare cost, hospital readmission and mortality. Early detection of CI may improve clinical outcomes in older adults with HF. Appropriate HF management strategies may also help to reduce CI in patients with HF, and future research is needed to develop and test newer and more effective interventions to improve outcomes in patients with HF and CI.

Heart Failure-Induced Brain Injury

Heart failure (HF) is a systemic illness with grave implications for bodily functions. The brain, among other vital organs, often suffers insults as a result of HF, and both anatomic and functional brain abnormalities were found in the HF population. This injury was demonstrated across a wide range of clinical conditions and cardiac functions and was shown to affect patients' outcomes. Although reduced cardiac output and high burden of cardiovascular risk factors are the prevailing explanations for these findings, there are data showing the involvement of neurohormonal, nutritional, and inflammatory mechanisms in this complex process. Here, the authors review the suggested pathophysiology behind brain injury in HF, describe its effect on patients' outcomes, offer a diagnostic approach, and discuss possible therapeutic options.

Pathogenesis of depression- and anxiety-like behavior in an animal model of hypertrophic cardiomyopathy

Cardiovascular dysfunction is highly comorbid with mood disorders, such as anxiety and depression. However, the mechanisms linking cardiovascular dysfunction with the core behavioral features of mood disorder remain poorly understood. In this study, we used mice bearing a knock-in sarcomeric mutation, which is exhibited in human hypertrophic cardiomyopathy (HCM), to investigate the influence of HCM over the development of anxiety and depression. We employed behavioral, MRI, and biochemical techniques in young (3-4 mo) and aged adult (7-8 mo) female mice to examine the effects of HCM on the development of anxiety- and depression-like behaviors. We focused on females because in both humans and rodents, they experience a 2-fold increase in mood disorder prevalence vs. males. Our results showed that young and aged HCM mice displayed echocardiographic characteristics of the heart disease condition, yet only aged HCM females displayed anxiety- and depression-like behaviors. Electrocardiographic parameters of sympathetic nervous system activation were increased in aged HCM females vs. controls and correlated with mood disorder-related symptoms. In addition, when compared with controls, aged HCM females exhibited adrenal gland hypertrophy, reduced volume in mood-related brain regions, and reduced hippocampal signaling proteins, such as brain-derived neurotrophic factor and its downstream targets vs. controls. In conclusion, prolonged systemic HCM stress can lead to development of mood disorders, possibly through inducing structural and functional brain changes, and thus, mood disorders in patients with heart disease should not be considered solely a psychologic or situational condition.-Dossat, A. M., Sanchez-Gonzalez, M. A., Koutnik, A. P., Leitner, S., Ruiz, E. L., Griffin, B., Rosenberg, J. T., Grant, S. C., Fincham, F. D., Pinto, J. R. Kabbaj, M. Pathogenesis of depression- and anxiety-like behavior in an animal model of hypertrophic cardiomyopathy.

The effect of patient anxiety and depression on motion during myocardial perfusion SPECT imaging

Background

Patient motion during myocardial perfusion SPECT imaging (MPI) may be triggered by a patient’s physical and/or psychological discomfort. The aim of this study was to investigate the impact of state anxiety (patient’s reaction to exam-related stress), trait anxiety (patient’s personality characteristic) and depression on patient motion during MPI.

Methods

All patients that underwent MPI in our department in a six-month period were prospectively enrolled. One hundred eighty-three patients (45 females; 138 males) filled in the State-Trait Anxiety Inventory (STAI) and the Beck Depression Inventory (BDI), along with a short questionnaire regarding their age, height and weight, level of education in years, occupation, and marital status. Cardiovascular and other co-morbidity factors were also evaluated. Through inspection of raw data on cinematic display, the presence or absence of patient motion was registered and classified into mild, moderate and severe, for both phases involved in image acquisition.

Results

The correlation of patient motion in the stress and delay phases of MPI and each of the other variables was investigated and the corresponding Pearson’s coefficients of association were calculated. The anxiety-motion (r = 0.43, P < 0.0001) and depression-motion (r = 0.32, P < 0.0001) correlation results were moderately strong and statistically significant for the female but not the male patients. All the other variables did not demonstrate any association with motion in MPI, except a weak correlation between age and motion in females (r = 0.23, P < 0.001).

Conclusions

The relationship between anxiety-motion and depression-motion identified in female patients represents the first supporting evidence of psychological discomfort as predisposing factor for patient motion during MPI.

The Impact of Body Mass Index on the Link Between Depressive Symptoms and Health Outcome in Patients With Heart Failure

BACKGROUND

Depressive symptoms are predictors of shorter cardiac event-free survival, whereas increased body mass index (BMI) is associated with longer cardiac event-free survival in patients with heart failure (HF). However, the impact of BMI on the link between depressive symptoms and cardiac event-free survival is unexplored. The purpose of this study was to determine whether the relationship between depressive symptoms and cardiac event-free survival differs among HF patients stratified by BMI tertiles.

METHODS

A total of 297 outpatients with HF completed the Patient Health Questionnaire-9 to assess depressive symptoms. Body mass index was calculated as weight in kilograms divided by height in meters squared. Patients were followed for 1 year to determine cardiac event-free survival. Cox proportional hazard regression with survival curves was used to determine the relationships among depressive symptoms, BMI, and cardiac event-free survival.

RESULTS

Both depressive symptoms (P < .001) and lower BMI (P = .002) are independent predictors of shorter cardiac event-free survival after controlling for age, gender, etiology, total comorbidity scores, ejection fraction, New York Heart Association functional class, and prescribed medications. Patients with depressive symptoms had shorter cardiac event-free survival compared with patients without depressive symptoms in the lowest (P = .001) and middle (P = .036) BMI tertiles. There was no difference in cardiac event-free survival between patients with and without depressive symptoms in the highest tertile (P = .894).

CONCLUSIONS

Higher BMI has a protective role in the adverse effect of depressive symptoms on health outcomes in patients with HF.

Comprehensive gene- and pathway-based analysis of depressive symptoms in older adults

Depressive symptoms are common in older adults and are particularly prevalent in those with or at elevated risk for dementia. Although the heritability of depression is estimated to be substantial, single nucleotide polymorphism-based genome-wide association studies of depressive symptoms have had limited success. In this study, we performed genome-wide gene- and pathway-based analyses of depressive symptom burden. Study participants included non-Hispanic Caucasian subjects (n = 6,884) from three independent cohorts, the Alzheimer's Disease Neuroimaging Initiative (ADNI), the Health and Retirement Study (HRS), and the Indiana Memory and Aging Study (IMAS). Gene-based meta-analysis identified genome-wide significant associations (ANGPT4 and FAM110A, q-value = 0.026; GRM7-AS3 and LRFN5, q-value = 0.042). Pathway analysis revealed enrichment of association in 105 pathways, including multiple pathways related to ERK/MAPK signaling, GSK3 signaling in bipolar disorder, cell development, and immune activation and inflammation. GRM7, ANGPT4, and LRFN5 have been previously implicated in psychiatric disorders, including the GRM7 region displaying association with major depressive disorder. The ERK/MAPK signaling pathway is a known target of antidepressant drugs and has important roles in neuronal plasticity, and GSK3 signaling has been previously implicated in Alzheimer's disease and as a promising therapeutic target for depression. Our results warrant further investigation in independent and larger cohorts and add to the growing understanding of the genetics and pathobiology of depressive symptoms in aging and neurodegenerative disorders. In particular, the genes and pathways demonstrating association with depressive symptoms may be potential therapeutic targets for these symptoms in older adults.

Interleukin-6 and tumor necrosis factor-α are associated with quality of life-related symptoms in pulmonary arterial hypertension

RATIONALE

Inflammation is associated with symptoms in many chronic illnesses; however, this link has not been established in pulmonary arterial hypertension.

OBJECTIVES

The objective of this study was to investigate the association between inflammatory markers and quality of life-related symptoms in patients with pulmonary arterial hypertension. We hypothesized that higher circulating IL-6 and tumor necrosis factor-α levels would be associated with worse quality of life-related symptoms.

METHODS

We performed a secondary analysis using baseline and 3-month assessments of 62 subjects in a clinical trial of aspirin and simvastatin to determine the association between plasma IL-6 and tumor necrosis factor-α levels and the Medical Outcomes Study Short Form-36 subscales (pain, vitality, mental health).

MEASUREMENTS AND MAIN RESULTS

The mean age was 49.7±13.4 years; 87% were female. Higher IL-6 levels were significantly associated with lower Medical Outcomes Study Short Form-36 subscale scores, indicating worse bodily pain, vitality, and mental health (all P<0.01). Higher tumor necrosis factor-α levels were significantly associated with increased bodily pain, but better mental health scores.

CONCLUSIONS

IL-6 and tumor necrosis factor-α levels are associated with certain quality of life domains in patients with pulmonary arterial hypertension. Clinical trial registered with www.clinicaltrials.gov (NCT00384865).

The link of unintentional weight loss to cardiac event-free survival in patients with heart failure

BACKGROUND

Patients with heart failure (HF) commonly have unintentional weight loss, depressive symptoms, and elevated levels of high-sensitivity C-reactive protein (hsCRP). Each of these variables has been independently associated with shorter cardiac event-free survival. However, little data exist on the relationships of unintentional weight loss, hsCRP level, and depressive symptoms to cardiac event-free survival.

OBJECTIVE

The aims of this study were to determine (1) whether depressive symptoms and elevated hsCRP level predicted unintentional weight loss and (2) whether unintentional weight loss predicted shorter cardiac event-free survival.

METHODS

This was a prospective study of 243 consecutive HF patients (61% men, 61 ± 14 years old) enrolled during an index hospitalization for HF exacerbation. Patients provided blood samples to measure hsCRP level and completed the Beck Depression Inventory to assess depressive symptoms at discharge. Body weight was measured at discharge and 6 months later. Unintentional weight loss was defined as weight loss of greater than 6% of body weight since discharge. Cardiac event-free survival was followed for 1 year after the second measurement of body weight through monthly telephone interviews. Hierarchical logistic regression was used to determine whether depressive symptoms and elevated hsCRP level predicted unintentional weight loss. Cox hazard regression was used to determine whether unintentional weight loss predicted cardiac event-free survival.

RESULTS

Thirty-five patients (14.4%) experienced unintentional weight loss at 6 months after discharge. Hierarchical Cox hazard regression revealed that patients with unintentional weight loss had a 3.2 times higher risk for cardiac events, adjusting for other clinical factors (P < .001). In hierarchical logistic regression, elevated hsCRP level (odds ratio, 1.49; 95% confidence interval, 1.15-1.92) and depressive symptoms (odds ratio, 1.07, 95% confidence interval, 1.02-1.12) independently predicted unintentional weight loss.

CONCLUSIONS

Unintentional weight loss was an independent predictor of poor outcomes. Heart failure patients with depressive symptoms and elevated hsCRP levels are at a higher risk for unintentional weight loss.

Association of interleukin-10 levels with age of onset and duration of illness in patients with major depressive disorder

OBJECTIVE

To investigate peripheral levels of interleukin-10 (IL-10) in patients with major depressive disorder (MDD) and bipolar disorder (BD) and evaluate the relationship between IL-10, age of disease onset, and duration of illness.

METHODS

Case-control study nested in a population-based cohort of 231 individuals (age 18-24 years) living in Pelotas, state of Rio Grande do Sul, Brazil. Participants were screened for psychopathology using the Mini-International Neuropsychiatric Interview (MINI) and the Structured Clinical Interview for DSM-IV (SCID-I). Serum IL-10 was measured using commercially available immunoassay kits.

RESULTS

Peripheral levels of IL-10 were not significantly different in individuals with MDD or BD as compared to controls. However, higher IL-10 levels were found in MDD patients with a later disease onset as compared with controls or early-onset patients. In addition, IL-10 levels correlated negatively with illness duration in the MDD group. In the BD group, age of onset and duration of illness did not correlate with IL-10 levels.

CONCLUSION

Higher levels of IL-10 are correlated with late onset of MDD symptoms. Moreover, levels of this cytokine might decrease with disease progression, suggesting that an anti-inflammatory balance may be involved in the onset of depressive symptoms and disease progression in susceptible individuals.

Insufficient glucocorticoid signaling and elevated inflammation in coronary heart disease patients with comorbid depression

Coronary heart disease (CHD) and depression are very common and often co-existing disorders. In addition to psychological and social morbidity, depression exacerbates adverse cardiac outcomes in CHD patients. Inflammation has been proposed as one of the mechanisms involved in the association between these two debilitating diseases. Therefore, the present study aimed to evaluate inflammatory responses as well as to investigate the pathophysiological mechanisms underlying the putative inflammatory activation in CHD patients with and without depression, by assessing the function of two important biological factors regulating inflammation, the hypothalamus-pituitary-adrenal (HPA) axis and the glucocorticoid receptor (GR). Eighty-three CHD patients with (n=28) and without (n=55) comorbid depression were recruited from primary care services in South London. Depression status was assessed by means of Clinical Interview Schedule Revised for diagnosis of depression, and Beck Depression Inventory for the presence of depressive symptoms. Serum C-reactive protein (CRP), plasma vascular endothelial growth factor (VEGF), and plasma and salivary cortisol were measured using commercially available ELISA kits. Gene expression of GR and interleukin-6 (IL-6) were conducted via qPCR. GR sensitivity was evaluated in vitro in isolated peripheral blood mononuclear cells using the dexamethasone inhibition of lipopolysaccharide-stimulated IL-6 levels. Serum levels of kynurenine pathway metabolites were measured using high performance liquid chromatography. Our results show that CHD patients with depression had higher levels of CRP, IL-6 gene expression, and VEGF compared with CHD non-depressed, as well as lower plasma and saliva cortisol levels. The CHD depressed group also exhibited a reduction in GR expression and sensitivity. Finally, tryptophan levels were significantly lower in patients with depression, who also showed an increased kynurenine/tryptophan ratio. In conclusion, CHD patients with depression had elevated levels of inflammation in the context of HPA axis hypoactivity, GR resistance, and increased activation of the kynurenine pathway. Reduced cortisol bioavailability and attenuated glucocorticoid responsiveness due to decreased expression and sensitivity of GR may lead to insufficient glucocorticoid signaling and thus elevation of inflammation in these patients.

Depressive symptoms and inflammatory biomarkers in patients with heart failure

BACKGROUND

Inflammation may be a link between depressive symptoms and outcomes in patients with heart failure. It is not clear whether inflammatory markers are independently related to depressive symptoms in this population.

AIM

To determine which inflammatory biomarkers are independently associated with depressive symptoms in heart failure.

METHODS AND RESULTS

We analyzed data from 428 outpatients enrolled in a heart failure registry (32% female, 61 ± 12 years, 48% New York Heart Association Class III/IV). Depressive symptoms were measured with the Beck Depression Inventory-II. Serum C-reactive protein (CRP), cytokines (interleukin 1 receptor antagonist, 2, 4, 6, 8, 10), tumor necrosis alpha, and soluble receptors sTNFR1 and sTNFR2 were measured with enzyme immunoassay. Multiple regressions were used to determine which biomarkers were associated with depressive symptoms controlling for demographics, heart failure severity, and clinical variables. Twenty-seven percent (n = 119) had depressive symptoms. CRP was related to depressive symptoms after controlling for age and gender, but no inflammatory biomarkers were associated with depressive symptoms after controlling for all variables in the model.

CONCLUSIONS

There was no relationship between inflammatory biomarkers and depressive symptoms. Our findings, in combination with prior researchers', suggest there is not a robust relationship between depressive symptoms and individual biomarkers of inflammation in heart failure.

In patients with stable heart failure, soluble TNF-receptor 2 is associated with increased risk for depressive symptoms

OBJECTIVES

Researchers have proposed biological (inflammation) and psychological (depression) factors as potential mechanisms for poorer outcomes and readmissions in heart failure (HF) patients. However, studies investigating the link between inflammation and depressive symptoms in these patients are few. We examined the relationships between levels of the inflammatory markers C-reactive protein (CRP), interleukin (IL)-6, and soluble tumor necrosis factor receptor 2 (sTNR2) and depressive symptoms in HF outpatients.

METHOD

55 patients (74.5% men; 60% Whites; mean age 71.6 ± 11.3 years) with New York Heart Association Class II, III, or IV HF (49%, 47%, and 4%, respectively) and mean ejection fraction (EF) 29.9 ± 7.1% completed the Patient Health Questionnaire (PHQ)-9 as a measure of depressive symptoms. We also obtained height, weight, and CRP, IL-6, and sTNFR2 levels. We used multivariate regressions to assess the predictive value of PHQ-9 scores on each inflammatory marker.

RESULTS

22 (40%) participants reported depressive symptoms (PHQ-9 score ≥ 5). After controlling for age, gender, body mass index, HF etiology, EF, and statin use, we found significant relationships between levels of both sTNFR2 (β = .35, p = .01) and IL-6 (β = .30, p = .04), but not CRP (β = -.96, p = .52), and depression scores.

CONCLUSION

Our findings add to a growing body of evidence supporting the proposition that heightened inflammation explains the effect depression has on HF. Health care providers should screen for depression in HF patients, as they may be at higher risk of augmented inflammation and poor outcomes.

Improving depression and reducing cardiac events: which is the chicken and which is the egg?

OBJECTIVE

To examine the assumption that depression leads to recurrent cardiac events and death in those with heart disease.

METHODS

Consideration of alternative perspectives and discussion of the literature.

RESULTS

It is not clear from studies like MIND-IT, ENRICHD or SADHART whether depression treatment improves cardiac outcomes. In these studies, recurrent cardiac events and death were recorded 6months or more after study entry, but shorter-term cardiac outcomes (e.g., stabilization of plaque prone to rupture and thrombosis or changes in areas of myocardium prone to life-threatening arrhythmia) were not assessed. Although the prevailing view is that shorter-term improvement in depression is necessary to improve cardiovascular outcomes, the possibility that shorter-term improvement in cardiac status might result in reduced symptoms of depression has not been examined. If correct, this possibility might explain why studies have shown that patients whose depression improves also exhibit improved cardiovascular outcomes and lower mortality, even though randomization to the depression intervention in these studies had no effect.

CONCLUSION

It is not clear whether improving depression comes first and reduced cardiac events follows or whether patients whose cardiac status improves also exhibit improvement in depression. Which is the chicken and which the egg is more than just a philosophical question, since it may affect the direction of future research in this field, and even how we approach the care of patients with heart disease and depression.

Depression and coronary heart disease

There are exciting findings in the field of depression and coronary heart disease. Whether diagnosed or simply self-reported, depression continues to mark very high risk for a recurrent acute coronary syndrome or for death in patients with coronary heart disease. Many intriguing mechanisms have been posited to be implicated in the association between depression and heart disease, and randomized controlled trials of depression treatment are beginning to delineate the types of depression management strategies that may benefit the many coronary heart disease patients with depression.

Positive affect dimensions and their association with inflammatory biomarkers in patients with chronic heart failure

BACKGROUND

In cardiac patients positive affect has found to be associated with improved clinical outcomes, with reduced inflammation being one of the potential mechanisms responsible.

METHODS

Positive affect was assessed using The Global Mood Scale (GMS), Positive and Negative Affect Schedule (PANAS), and Hospital Anxiety and Depression Scale (HADS) in patient with chronic heart failure (N=210; 67 ± 9 years, 79% men). Markers of inflammation (TNFα, sTNFr1, sTNFr2, IL-6 and CRP) were measured and averaged at three consecutive time points.

RESULTS

The positive affect dimensions of the GMS and PANAS were significantly associated with lower averaged levels of sTNFr2, TNFα and IL-6 (p<.1), even after adjustment for clinical and lifestyle confounders. Positive affect of the HADS was significantly associated with lower averaged levels of hsCRP (p<.1), but was no longer significant after correction for lifestyle confounders and depressive symptoms.

CONCLUSION

Positive affect is associated with reduced inflammation in patients with heart failure.

Does depression impact cognitive impairment in patients with heart failure?

Prevalence studies have noted the cooccurrence of cognitive decline and depression in persons with heart failure. Cognitive impairment is associated with significant mortality and deteriorated quality of life, likely due to impairments in memory and executive function, which impact a patient's ability to understand and comply with prescribed treatment plans. This is especially true in complex diseases such as heart failure. Evidence from literature supports the possibility of a pathophysiological relationship between cognitive impairment, depression, and heart failure. Yet, very few studies have sought to investigate this relationship. This paper reviews current literature on the association between depression and cognitive impairment in persons with heart failure and explores possible mechanisms explaining this complex triad.

Predictors of re-hospitalization in patients with chronic heart failure

Heart failure (HF) is a chronic, progressive illness that is highly prevalent in the United States and worldwide. This morbid illness carries a very poor prognosis, and leads to frequent hospitalizations. Repeat hospitalization in HF is both largely burdensome to the patient and the healthcare system, as it is one of the most costly medical diagnoses among Medicare recipients. For years, investigators have strived to determine methods to reduce hospitalization rates of HF patients. Despite such efforts, recent reports indicate that re-hospitalization rates remain persistently high, without any improvement over the past several years and thus, this topic clearly needs aggressive attention. We performed a key-word search of the literature for relevant citations. Published articles, limited to English abstracts indexed primarily in the PubMed database through the year 2011, were reviewed. This article discusses various clinical parameters, serum biomarkers, hemodynamic parameters, and psychosocial factors that have been reviewed in the literature as predictors of re-hospitalization of HF patients. With this information, our hope is that the future holds better risk-stratification models that will allow providers to identify high-risk patients, and better customize effective interventions according to the needs of each individual HF patient.

Cognitive/affective and somatic/affective symptom dimensions of depression are associated with current and future inflammation in heart failure patients

BACKGROUND

Little is known about whether cognitive/affective depressive symptoms or somatic/affective depressive symptoms are associated with inflammation in heart failure (HF), or that the relation is confounded with disease severity.

AIM

To examine the association between depressive symptom dimensions in HF patients with inflammatory markers cross-sectionally and prospectively, while adjusting for appropriate confounders.

RESULTS

Consecutive HF patients completed the Beck Depression Inventory at inclusion and at 12 month follow-up. Cytokines were assessed at both occasions. Cross-sectional--multivariate linear regression analysis (n=110) demonstrated that cognitive/affective depressive symptoms were independently associated with increased levels of sTNFR2 (β=0.20, p<0.05) and IL-1ra (β=0.28, p<0.01). Somatic/affective depressive symptoms were independently related to sTNFR2 (β=0.21, p<0.05). Prospective--(n=125) the level of cognitive/affective depressive symptoms at inclusion was prospectively associated with increased levels of sTNFR1 and sTNFR2 (β=0.21 and 0.25 resp. p<0.05), independent of covariates. Change in somatic/affective depressive symptoms over the 12 month period was associated with sTNFR2 (β=0.30, p=0.008). At symptom level, core depressive cognitions such as hopelessness and guilt drove the relation between the sTNF receptors and the cognitive/affective component, while having sleep problems was the most important associate of the somatic/affective dimension.

CONCLUSIONS

Baseline cognitive/affective depressive symptoms were prospectively associated with sTNFR1 and sTNFR2 in HF patients, while change in somatic/affective depressive symptoms was associated with sTNFR2, independent from clinical and demographic covariates. Further studies are warranted to replicate these findings and to examine the association between depression dimensions, inflammation and prognosis in HF.

Antidepressive effect of mirtazapine in post-myocardial infarction depression is associated with soluble TNF-R1 increase: data from the MIND-IT

BACKGROUND

Depressive disorder after myocardial infarction (MI) is associated with increased cardiac morbidity and mortality. Immune activity such as inflammation might be implicated as an underlying mechanism. The purpose of this study is to investigate whether the response to an antidepressant in post-MI depression is associated with changes of inflammatory markers in serum.

METHODS

In a double-blind placebo-controlled study with mirtazapine 30 mg/day (50 patients), the antidepressive effect was related to immune activation parameters. The cytokines interleukin 6 (IL-6) and tumor necrosis factor α (TNF-α), the soluble cytokine receptors sIL-6R, sTNF-R1 and sTNF-R2, and the inflammation-sensitive plasma proteins C-reactive protein and neopterin were assessed.

RESULTS

Subgroup analyses revealed a highly significant correlation of pronounced sTNF-R1 increase with a decrease in depressive symptoms in antidepressant responders.

CONCLUSION

Significant effects on inflammation accompany the therapeutic efficacy of mirtazapine in contrast to the therapeutic efficacy of placebo and the nontherapeutic efficacy of mirtazapine.

Depressive symptoms and inflammation in patients hospitalized for heart failure

BACKGROUND

Depressive symptoms in patients with heart failure (HF) are common and might be associated with inflammation. No studies have examined both the cross-sectional and prospective association between inflammation and depressive symptoms in patients with HF with adequate correction for disease severity. The aim of this study was to describe if the cytokines interleukin-6 (IL-6) and C-reactive protein (CRP) are associated with depressive symptoms in hospitalized HF patients.

METHODS

Data from 517 patients hospitalized for HF from the COACH study were analyzed on inflammation markers (IL-6 and CRP) and depressive symptoms (Center for Epidemiological Studies Depression-Scale).

RESULTS

Heart failure patients with depressive symptoms (n = 208, 40%) had significantly higher plasma values of IL-6 (median 12.8 pg/mL vs median 11.0 pg/mL, P = .018) and CRP (median 2.4 mg/mL vs median 2.1 mg/mL, P = .03) compared with the nondepressed patients. Structural equation modelling showed that the factor inflammation (including IL-6 and CRP) was associated with depressive symptoms (β = 0.18, P < .05) when left ventricular ejection fraction and plasma values brain natriuretic peptides were included in the model. A small negative (β = -0.18, P < .05) effect was found between inflammation at baseline and the change in depressive symptoms during the 18 months of follow-up.

CONCLUSIONS

Higher levels of inflammatory markers are independently associated with depressive symptoms in HF patients, even after correcting for disease severity. There is no clear relationship between inflammation at baseline and depressive symptoms during the 18 months of follow-up.

Lymphocytes in neuroprotection, cognition and emotion: is intolerance really the answer?

Clinical, epidemiological and therapeutic studies indicate that some human depression is associated with proinflammatory cytokines, chronic inflammatory disorders, and inflammation-inducing lifestyle factors. Moreover depression can be induced by administration of proinflammatory cytokines, including IL-2 or IFN-α. However, recent studies in specific pathogen-free (SPF) rodents suggest a different--and potentially contradictory--relationship between immune processes and mental health. These studies suggest that effector T cells specific for central nervous system (CNS) antigens can assist recovery from an array of environmental insults ranging from nerve injury to psychological stress, while in contrast, regulatory T cells (Treg) oppose such recovery. Indeed, some reported effects of this so-called "protective autoimmunity" seem of direct relevance to depressive disorders. These findings pose a dilemma for those intending to manipulate inflammatory pathways as a treatment for depression. Should we administer anti-inflammatory treatments, or should we induce self-reactive T cells? We re-examine the rodent findings and outline immunological peculiarities of SPF rodents, the abnormal properties of their regulatory T cells, and the impact of gut microbiota. We find that "protective autoimmunity" is likely to be relevant only to very clean SPF animals that lack normal levels of activated T cells, CNS T cell traffic and mature Treg. The data indicate that even in SPF models the effectors of beneficial effects are not the proinflammatory autoimmune cells themselves, but rather unidentified regulatory cells. This reinterpretation of findings relevant to "protective autoimmunity" suggests that ongoing, and planned, clinical trials of anti-inflammatory strategies to treat depressive disorders are justified.

Health-related quality of life is related to cytokine levels at 12 months in patients with chronic heart failure

Chronic heart failure (CHF) is a condition with a high mortality risk. Besides traditional risk factors, poor health-related quality of life (HRQoL) is also associated with poor prognosis in CHF. Immunological functioning might serve as a biological pathway underlying this association, since pro and anti-inflammatory cytokines are independent predictors of prognosis. The aim of this study was to examine the association between HRQoL at inclusion (baseline) and pro and anti-inflammatory cytokine levels both at baseline and 12months, using a prospective study design. CHF outpatients completed the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the Short Form Health Survey 36 (SF-36). Blood samples were drawn at baseline (n=111) and 12months (n=127) to measure pro (IL-6, TNFalpha, sTNFR1, sTNFR2) and anti- (IL1ra, IL-10) inflammatory markers. Linear regression analysis were run for the MLHFQ, the SF-36 mental component summary (MCS) and the physical component summary (PCS), controlling for age, sex, BMI, smoking, co morbidity, NYHA-class and 6min walk test. Baseline MLHFQ was associated with increased levels of baseline sTNFR2, and 12-month sTNFR1 12month sTNFR2. Baseline MCS and change in MCS were related to increased 12-month sTNFR1 levels. All significant findings relate a worse HRQoL at baseline or a deterioration over time to increased sTNFR1/2 levels. These findings suggest that immune activation may be one of the pathways underlying the relationship between poor HRQoL and mortality and morbidity in CHF patients. Future studies are warranted to replicate these findings in larger samples.

Depression and perceptions about heart failure predict quality of life in patients with advanced heart failure

BACKGROUND

Mood is an independent predictor of mortality and quality of life (QoL) for people with heart failure. However, the underlying belief systems involved in mood are unknown.

OBJECTIVE

We sought to identify psychological and clinical variables predicting mood and QoL for people diagnosed with heart failure (HF).

METHODS

One hundred and forty-six HF patients were assessed with standardized measures, to determine their beliefs about HF, coping styles, mood, and QoL.

RESULTS

Patients with more negative beliefs about the consequences of HF and with less perceived control over symptoms showed maladaptive coping styles such as denial and behavioral disengagement, and more severe levels of depression and anxiety. Depression also independently predicted QoL outcomes.

CONCLUSIONS

Anxious and depressed patients have more negative beliefs about HF, leading to negative coping behaviors and poor QoL. Our evidence suggests that changing negative beliefs may improve the psychological well-being and QoL of patients, irrespective of disease severity.

Depression and related psychological factors in heart disease

In this article we review the role of depression and other related psychological factors in heart disease. The prevalence of heart disease in patients with depression is high, and epidemiological links between depression and heart disease are evident in studies of community samples, psychiatric patients, and heart disease patients. We also describe the links between heart disease and related psychological factors-including vital exhaustion, Type A behavior pattern, anger and hostility, and Type D personality-and summarize proposed mechanisms that may link negative affects with heart disease. Finally, we review treatment of depression in heart disease, including evidence from several large clinical trials.

A meta-analysis of cytokines in major depression

BACKGROUND

Major depression occurs in 4.4% to 20% of the general population. Studies suggest that major depression is accompanied by immune dysregulation and activation of the inflammatory response system (IRS). Our objective was to quantitatively summarize the data on concentrations of specific cytokines in patients diagnosed with a major depressive episode and controls.

METHODS

We performed a meta-analysis of studies measuring cytokine concentration in patients with major depression, with a database search of the English literature (to August 2009) and a manual search of references.

RESULTS

Twenty-four studies involving unstimulated measurements of cytokines in patients meeting DSM criteria for major depression were included in the meta-analysis; 13 for tumor necrosis factor (TNF)-alpha, 9 for interleukin (IL)-1beta, 16 for IL-6, 5 for IL-4, 5 for IL-2, 4 for IL-8, 6 for IL-10, and 4 for interferon (IFN)-gamma. There were significantly higher concentrations of TNF-alpha (p < .00001), weighted mean difference (WMD) (95% confidence interval) 3.97 pg/mL (2.24 to 5.71), in depressed subjects compared with control subjects (438 depressed/350 nondepressed). Also, IL-6 concentrations were significantly higher (p < .00001) in depressed subjects compared with control subjects (492 depressed/400 nondepressed) with an overall WMD of 1.78 pg/mL (1.23 to 2.33). There were no significant differences among depressed and nondepressed subjects for the other cytokines studied.

CONCLUSIONS

This meta-analysis reports significantly higher concentrations of the proinflammatory cytokines TNF-alpha and IL-6 in depressed subjects compared with control subjects. While both positive and negative results have been reported in individual studies, this meta-analytic result strengthens evidence that depression is accompanied by activation of the IRS.

Circulating levels of soluble intercellular adhesion molecule-1 (sICAM-1) independently predict depressive symptom severity after 12 months in heart failure patients

OBJECTIVE

To determine whether inflammatory markers prospectively predict depressive symptom severity 12 months later in heart failure (HF) patients.

METHODS

In 30 HF patients we assessed depressive symptom severity by the Beck depression inventory (BDI) at baseline as well as 12 months later. We measured circulating levels of the soluble intercellular adhesion molecule (sICAM)-1, the cytokine interleukin (IL)-6 and the acute phase protein C-reactive protein (CRP) at baseline assessment.

RESULTS

sICAM-1 (r=.38, p=.045) but not CRP or IL-6 correlated with BDI scores 12 months later. Hierarchical linear regression analysis revealed that independent of baseline BDI assessment, cardiovascular risk factors, indicators of HF disease severity, and medication intake, sICAM-1 significantly predicted BDI scores 12 months later. sICAM-1 independently explained between 7% (beta=.26, p=.040) and 10% (beta=.35, p=.045) of the total variance in BDI scores 12 months later.

CONCLUSION

The findings from this exploratory analysis suggest that the adhesion molecule sICAM-1 is an independent predictor of depressive symptoms 12 months later in HF patients. Our prospective findings support the suggested role for inflammation in increasing future depressive symptom severity and extend this linkage for the first time to HF.

Depressive symptoms and metabolic syndrome: selective association in older women

The metabolic syndrome (MetS) is being increasingly found in older populations. Depressive symptoms are prevalent in elderly populations, and they are associated with adverse outcomes, chiefly cardiovascular. The aim of this study was to evaluate the association of the 30-item geriatric depression scale (GDS) score with MetS, as defined according to the National Cholesterol Education Program's Adult Treatment Panel III (ATP-III) criteria, in all 353 participants aged 75+ years living in Tuscania (Italy). Metabolic syndrome was associated with the GDS score in a multivariable linear regression analysis in women (beta s= 2.14, 95% CI = 0.14 to 4.14; P = .036), but not in men (beta = -.84, 95% CI = -3.17 to 1.49; P = .476), after adjusting. Analysis of the interaction term confirmed (P = .022) that such an association differed according to sex. Metabolic syndrome is independently associated with depressive symptoms in community-dwelling older women. Older women with depression should be prompted to undergo screening for MetS. Conversely, elderly women with MetS should be assessed for affective disorders.

Broad spectrum of cytokine abnormalities in panic disorder and posttraumatic stress disorder

BACKGROUND

Proinflammatory cytokines have been reported to be elevated in individuals experiencing chronic stress as well as in those with major depressive disorder. Much less is known about cytokines in anxiety disorders such as posttraumatic stress disorder (PTSD) and panic disorder (PD). We hypothesized that PD and PTSD would be associated with a generalized proinflammatory cytokine signature.

METHOD

We utilized Luminex technology to examine 20 cytokines and chemokines in serum from 48 well-characterized individuals with a primary DSM-IV PD or PTSD diagnosis, and 48 age- and gender-matched healthy controls. We conservatively employed a Bonferroni correction for multiple testing (alpha=.05/20=.0025).

RESULTS

Individuals with primary PTSD or PD had significantly elevated median peripheral cytokine levels for 18 of 20 different cytokines compared to age- and gender-matched healthy controls (all P<.0025). To assess for the presence of a generalized proinflammatory state, we also examined the proportion of subjects with detectable levels of at least six of nine common proinflammatory cytokines and chemokines (IL-6, IL-1alpha, IL-1beta, IL-8, MCP-1, MIP-1alpha, Eotaxin, GM-CSF, and IFN-alpha). For men and women, 87% of anxiety patients had six or more detectable levels of these proinflammatory cytokines, compared with only 25% of controls (Fisher's Exact Test (FET) P=.000). Confirmatory analysis of the subset of individuals without current psychiatric medication use or comorbid depression was of comparable significance.

CONCLUSIONS

These findings suggest that a generalized inflammatory state may be present in individuals with PD or PTSD.

[Psychoneuroimmunology: an update]

Psychoneuroimmunology (PNI) is closely associated with the bidirectional pathways between mind/brain and the immune system. PNI research represents a rapidly growing area within psychosomatic research. Recent studies in PNI are based mainly on the immunological concepts of Th1/Th2 dichotomy and inflammation. This review covers human PNI studies dealing with stress-associated changes in cytokine (Th1, Th2) levels in immune-related processes such as wound healing, atopic diseases as well as autoimmune and other inflammatory diseases. It is shown that PNI studies measuring immune activity near the site of the disease (e. g. woundhealing) and dealing with objective stressors show more consistent findings (stress-associated Th1/Th2 shift, stress-associated proinflammatory activation) than those dealing with chronic and complex diseases (e. g., autoimmune disease). This warrants the expansion of the methodological repertoire in future PNI research toward designs allowing for the investigation of complex psychosomatic phenomena.